Bariatric Surgery Guidelines

Updated: Feb 16, 2021
  • Author: Alan A Saber, MD, MS, FACS, FASMBS; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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ESPGHAN Guidelines for Bariatric Surgery in Children

In January 2015, the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) published a position statement on bariatric surgery for severely obese children and adolescents, which provided the following guidelines [10] :

  • Consider bariatric surgery in "carefully selected" patients with a body mass index (BMI) higher than 40 kg/m 2 who have severe comorbidities (eg, nonalcoholic fatty liver disease [NAFLD]) or in those with a BMI higher than 50 kg/m 2 who have milder comorbidities
  • Additional factors to consider in deciding whether a child or adolescent should undergo bariatric surgery include physical and psychological maturity, personal desire to undergo the procedure, previous attempts at weight loss, and ability to adhere to follow-up care
  • Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and sleeve gastrectomy are the most widely used procedures in pediatric obesity, but their use is associated with subsequent nutritional deficiencies; temporary intragastric devices could represent a better option for initial treatment in pediatric populations
  • Current evidence suggests that bariatric surgery can decrease the grade of steatosis, hepatic inflammation, and fibrosis in NAFLD
  • Uncomplicated NAFLD is not an indication for bariatric surgery
  • Roux-en-Y gastric bypass is considered a safe and effective option for extremely obese adolescents, as long as appropriate long-term follow-up is provided
  • Laparoscopic adjustable gastric banding has not been approved by the FDA for use in adolescents and therefore should be considered investigational
  • Sleeve gastrectomy and other types of weight loss surgery that have grown increasingly common in adults must still be considered investigational

DSS-II Guidelines for Bariatric/Metabolic Surgery in Type 2 Diabetes

In June 2016, the 2nd Diabetes Surgery Summit (DSS-II), an international consensus conference, issued the following global guidelines regarding the benefits and limitations of bariatric/metabolic surgery for type 2 diabetes mellitus [11] :

  • Metabolic surgery should be a  recommended option to treat type 2 diabetes mellitus in appropriate surgical candidates with class III obesity (BMI ≥40 kg/m 2), regardless of the level of glycemic control or complexity of glucose-lowering regimens, as well as in patients with class II obesity (BMI 35.0-39.9 kg/m 2) with inadequately controlled hyperglycemia despite lifestyle and optimal medical therapy
  • Metabolic surgery should also be  considered to be an option to treat type 2 diabetes in patients with class I obesity (BMI 30.0-34.9 kg/m 2) and inadequately controlled hyperglycemia despite optimal medical treatment by either oral or injectable medications (including insulin)
  • All BMI thresholds should be reconsidered depending on the ancestry of the patient; for example, for patients of Asian descent, the BMI values above should be reduced by 2.5 kg/m 2
  • Metabolic surgery should be performed in high-volume centers with multidisciplinary teams that understand and are experienced in the management of diabetes and gastrointestinal surgery
  • Ongoing and long-term monitoring of micronutrient status, nutritional supplementation, and support must be provided to patients after surgery, according to guidelines for postoperative management of bariatric/metabolic surgery by national and international professional societies
  • Metabolic surgery is a potentially cost-effective treatment option in obese patients with type 2 diabetes; the clinical community should work together with health care regulators to recognize metabolic surgery as an appropriate intervention for type 2 diabetes in people with obesity and to introduce appropriate reimbursement policies